As managing editor of the Science-Based Medicine (SBM) blog, I am writing this post because our founder and exective editor Dr. Steven Novella was invited to be on The Doctor Oz Show. Later today, the episode in which he will appear will air in most of your local markets, and we wanted to make sure that any Dr. Oz viewer who sees the segment and as a result is intrigued (or angered) enough to wonder what it is that we are all about will have a convenient “primer,” so to speak, on the problem with Dr. Oz from a science-based perspective. In other words, who are these obnoxious upstart bloggers who are so critical of Dr. Oz are and, far more importantly, exactly why are we so critical? What is science-based medicine, anyway?

What is science-based medicine?

Many readers have likely heard the term “evidence-based medicine” (EBM). It’s a (relatively) new buzzword designed ostensibly to describe medicine that is based on solid evidence, in contrast to much medicine practiced in the past that may or may not have been based on solid evidence. Indeed, I sometimes jokingly refer to some forms of medicine, particularly from more than a few decades ago, as “dogma-based” medicine or “tradition-based” medicine. We at SBM, however, have noted a problem with EBM. Specifically, EBM elevates clinical trial data to the highest level of its “hierarchy of evidence,” in particular, randomized, double blind clinical trial data. Under normal circumstances, where new treatments are developed “organically” from basic science and clinical observations, through preclinical experimentation (biochemistry, in vitro work, cell culture, and animal models), all the way to clinical trials, it is correct to rank randomized clinical trials as the “gold standard” of scientific evidence for or against a particular therapy. After all, many are the therapies and drugs that look promising in preclinical investigations, only to fail when tested in humans, many more than the therapies and drugs that succeed and prove their worth. Here’s the problem with EBM. While EBM works well for science-based medical interventions, it has a distressing tendency to break down when applied to medical interventions that are, from a basic scientific standpoint, highly improbable. And I’m not just talking mildly improbable, either, but interventions that are incredibly improbable.

To try to explain, my favorite example of this phenomenon is homeopathy. Homeopathy, you see, is improbable. Really improbable. You just won’t believe how hugely, mindbogglingly improbable it is. (Apologies to Douglas Adams.) Basically, homeopathy postulates two “laws,” the law of similars and the law of infinitesimals. The law of similars states that “like cures like”; for example, something that causes itching (poison ivy, for instance) can be used to cure itching. The law of infinitesimals then states that the more you dilute a remedy, the stronger it gets. It also postulates that the remedy is “potentized” by vigorous shaking between each dilution. A typical homeopathic remedy is diluted 30C, each “C” being a 100-fold dilution, which makes 30C a mixture that’s been diluted 100-fold thirty times. This results in a 1060-fold dilution, a one with sixty zeroes after it (by comparison, a trillion is represented by a one with twelve zeroes after it). To understand the significance of this, you need to know that a unit that chemists use to measure quantities of chemicals is the mole. One mole is roughly 6 x 1023 molecules. (One mole of table sugar, sucrose, for instance, weighs approximately 342 grams, which is less than 14 oz.) What this means is that typical homeopathic remedies are diluted way, way, way beyond the point where not a single molecule of original remedy remains. Indeed, some homeopathic remedies go up to 200C, which is a 10400-fold dilution. By comparison, the number of molecules in the known universe is estimated to be between 1078 and 1082. Clearly, for homeopathy to work, huge swaths of what we know about chemistry, physics, and biology would have to be not just wrong, but spectacularly wrong. It’s about as close to being impossible as can be imagined in modern science. Yet Dr. Oz promoted homeopathy on his show not long ago, and millions still swear by it.

Why?

Given that homeopathy is nothing more than water, one reason is nonspecific placebo effects. Combine placebo effects with the fact that, by design based on the way we calculate whether the results of a clinical trial are statistically “significant,” at least 5% of clinical trial results will be false positives; i.e., give a “positive” result when the treatment really doesn’t work. This is true for drugs as well as implausible remedies like homeopathy. In fact, it’s considerably higher than a 5% chance of a false positive, because the 5% number is more theoretical than anything else. It applies only when a clinical trial is perfectly designed and perfectly carried out, and there’s no such thing as a perfect clinical trial. Unfortunately, EBM does not take into account the extreme implausibility of a treatment like, for example, homeopathy, reiki, therapeutic touch, or many other “energy healing” methods. Clinical trials are all that matter, and the flaws in clinical trials can lead to the appearance that such remedies have an effect. SBM, in marked contrast, is evidence-based medicine that takes scientific plausibility into account. Because all the ins and outs of SBM could take up a book, we’ve written up a primer describing the concept of SBM, along with a bunch of links for those interested in learning more about it. Personally, I suggest starting with four posts:

The bottom line is that we at SBM reject the whole concept of “alternative health” in the title of Dr. Oz’s segment featuring Steve Novella. “Alternative medicine” represents a false dichotomy. Indeed, I frequently repeat an old joke that asks: What do you call alternative medicine that has been scientifically proven to work?

The answer: Medicine.

That’s because alternative medicine by definition is medicine that either hasn’t been scientifically proven to work or has been scientifically proven not to work, while “integrative medicine” is nothing more than “integrating” unproven “alternative” medicine with medicine scientifically proven to work.

Which finally brings us back to Dr. Oz.

The trouble with Dr. Oz

I can’t speak for the rest of the bloggers here at SBM, but up until about a year ago, I really didn’t have that much of a problem with Dr. Oz. I really didn’t. Admittedly, he did annoy me a bit with his tendency towards credulity towards certain forms of dubious medicine, such as reiki (which, when you come right down to it, is faith healing based on Eastern mysticism rather than Christianity). Also admittedly, I found Dr. Oz’s on-air persona to be a bit on the cheesy side. However, for the most part, before he got his own show and even early on after he got his own show, most of Dr. Oz’s health advice was at least semi-reasonable, much of it even science-based. As time went on, however, we did notice that, more and more, Dr. Oz seemed to want to “go with the flow” and “give the people what they want.” Why? we wondered. Dr. Val Jones, formerly a regular blogger for SBM, thought she knew the answer:

I told him [a business colleague] that I was contributing to a blog called Science-Based Medicine in an effort to combat some of the medical quackery that is being promoted online. He looked at me and said I’d never be a success with that message. He said that people like Oprah and Mehmet Oz were successful because they “went with the flow” and gave people what they wanted.

“Most people don’t want to think critically about things – they want to hear about miracle cures, self-help, and vitamins. They already have the media they ‘deserve.’ You’ll never appeal to a mass audience with your skeptical message.”

Even if that’s true, we view it as our mission to try to change that and encourage as many people as we can reach to learn to think critically about medicine.

So why would Steve agree to be on Dr. Oz’s show? It was a difficult decision, actually. Even in our wildest dreams we had no idea that our criticisms were even being noticed by Dr. Oz or his producers, much less having any effect. So, on the one hand, we were grateful to Dr. Oz’s producers for inviting our representative on the show. On the other hand there was very little time for Steve to make a decision, much less prepare, and, given Dr. Oz’s history, Steve and the rest of us were all—understandably, I believe—wary about how he might end up being portrayed. In the end, given that the mission of this blog is to promote science in medicine and medicine based on good science, we agreed that this invitation was an opportunity that we had to seize, even knowing the risk that Steve might be portrayed unfavorably. Even though, as I write this, I haven’t seen the episode yet, I have seen the preview. What I see is that my fears weren’t unfounded. The very title (“Controversial medicine: Why your doctor is afraid of alternative health”) is clearly slanted against the SBM point of view. Worse, even in just the brief promo clip presented, Dr. Oz:

Challenges Steve by asking, “Why do you not want me to talk about these therapies on the show?” This is a distortion of our position. Nothing could be further from the truth to claim that we don’t want Dr. Oz to talk about these therapies. What we don’t wnat him to do is to promote them as efficacious when they are not. What we want is a skeptical, science-based assessment of them. Despite the claim by Dr. Oz and his producers that we are “afraid” of alternative health, in actuality we crave an open dialogue based on science, both preclinical and clinical trials, not marketing hype, pseudoscientific claims, and testimonials.

Says it’s “very dismissive” of Steve to challenge these therapies as not working. This is the infamous “don’t be close-minded” gambit. Of course, the problem with being too open-minded is that your brains might fall out.

Still, that Dr. Oz apparently was sufficiently stung by our criticisms over the last several months that he felt the need to have Dr. Novella on his show tells me that there may well be more hope than is readily obvious. My optimism aside, though, it’s impossible for us to deny that at huge part of the reason that Dr. Oz’s show is so successful is, no doubt, because he does “go with the flow,” serving up for the most part lightweight, fluffy, uplifting entertainment which sometimes contains good medical information. In this, he clearly learned at the feet of the Master, his mentor and the person who got him started as a media doctor, Oprah Winfrey, who has come under considerable criticism herself for promoting pseudoscience and New Age mystical beliefs. He’s also apparently learned at the feet of Oprah how to gin up a controversy, as his promo for Steve’s appearance shows.

Most disturbingly, though, of late Dr. Oz has been also promoting pseudoscience and what can only be described, in my opinion, as quackery. The snake oil that Dr. Oz has promoted over the last several months includes Dr. Joe Mercola, one of the biggest promoters of “alternative” health, whom Dr. Oz first had on his show about a year ago and then defiantly defended in a return appearance in early 2011. Then, in a rapid one-two punch, Dr. Oz had an ayurvedic yogi named Cameron Alborzian, who promoted highly dubious medicine, including “tongue diagnosis,” to be followed a few days later by something I would never, even in my most cynical assessment of Dr. Oz, expected, namely the appearance of faith healer Issam Nemeh on his show. Worse, Dr. Oz showed zero signs of skepticism. Unfortunately, Dr. Oz wasn’t done. In rapid succession next Dr. Oz endorsed a diet that he once eschewed as quackery and then, to top it all off, invited psychic John Edward onto his show, asking Is talking to the dead a new kind of therapy? This latter episode so shocked me that I basically said, “Stick a fork in him, Dr. Oz is done when it comes to SBM.”

Dr. Oz’s descent was complete, and that is now the trouble with Dr. Oz and much of the reason why in 2011 the James Randi Educational Foundation awarded him the The Media Pigasus Award for the second year in a row. I fear he very well may three-peat in 2012. The only thing that might save him is listening to his critics, but I fear that is unlikely. We’ll see.

Further reading about Dr. Oz

I hope you, our regular readers, will comment on Dr. Novella’s appearance, both here and in Dr. Novella’s post about his experience, the latter of which will be posted this evening after he gets a chance to see how the segment turned out after editing. I also invite Dr. Oz viewers to join in. Just register a user name and password here. In the meantime, here is a collection of critical posts and articles about Dr. Oz. Also, don’t forget to dive into the discussion forums at Dr. Oz’s website after the episode with Steve airs in your area.

Fans of Dr. Oz who come here may look at that list of critical posts and think this blog has some personal grudge against him. Some of you won’t be persuaded otherwise no matter what the evidence.

However, I sincerely urge all new visitors to read some of those posts and judge their criticisms based on the evidence. If you do, I’m confident you will see the truth of the matter. The things that Oz promotes are not good medicine. They are self delusion at best, and outright fraud at worst.

Fans of Dr. Oz who come here may look at that list of critical posts and think this blog has some personal grudge against him.

Well, given that we’ve done hundreds of posts over the last three years, five posts on SBM and one post on NeuroLogica are not actually that many posts. At least we don’t have a separate category for Dr. Oz, although to be honest the thought of creating one, to go up alongside “Acupuncture” and “Homepathy” has crossed my mind.

Looking forward to it… (Scared out of my mind)
At the end of the day it was the right decision to go on the show however Steve is portrayed. When your view is not the popular opinion then any publicity is good publicity. This is especially true with something like the dr Oz show that has the biggest medicine soap box out there.

I’ve noticed on a couple of websites and Facebook pages some antivaxxers and alt med types are mobilising their friends to watch this episode of Dr Oz.
They’ve written the following quote, the quotes are theirs, in a couple of places without attribution.

“Dr. Oz brought the best Integrative Medicine doctor in the USA, Dr. Mimi Guarneri, to defend alternative medicine. That’s like bringing a Harvard PhD to debate a kindergarten student. Dr. Guarneri is so much more impressive than Dr. Novella.”

The biggest problem, I think, is the fact that this means Dr. Oz can’t be trusted on any other issues either. Once someone has demonstrated a willingness to ignore facts in one area, you can never be sure about any of their other pronouncements.

Once someone has demonstrated a willingness to ignore facts in one area, you can never be sure about any of their other pronouncements.

So true Scott,and that is the reason why Dr. Oz should take these criticisms seriously.The Skeptical community will not ever let a high profile Dr. off the hook until they show that they have respect for the scientific method and good evidence.The Skeptical movement is growing worldwide,and as Dr. Novella has pointed out, “is punching above their weight”.

I agree with Scott. I have no problem recognizing that homeopathy, reiki, acupuncture, and the like are bogus. I don’t have the medical training to judge many other things Oz might recommend, but his willingness to support bogus ‘treatments’ casts doubt on all aspects of his medical authority.

I don’t mean to suggest that everything Oz says is wrong. I’m certain that’s not the case. Just that his acceptance of so many things I know are bogus makes it impossible to know which of his other claims might also be bogus.

I agree that it was the correct decision, regardless of the outcome. If it wasn’t Steve, then the producers would get someone else who is potentially less qualified to do the job and would represent our viewpoint poorly. Let’s face it, they’d run the program regardless of who was the guest just to try an shut-up the “nay-sayers.”

Of course, one wonders who would be able (or willing) to do this on such short notice. The producers basically gave Steve three days’ warning. They asked him on a Tuesday morning; the taping was on a Friday afternoon. That Tuesday afternoon and evening were very busy ones for SBM members debating what to do over e-mail. It was very fortunate that Steve was even able to rearrange his schedule to be able to do it on such short notice. I probably couldn’t have. Steve is Yale faculty, which makes things somewhat easier.

Not too long ago I angered a floor nurse over Dr. Oz. His show was on the breakroom TV, and I made some comment about his rank quackery. More specifically, I think I brought up the faith healing and psychics. She said something to the effect of “I don’t care what anybody says, I love Dr. Oz.” That about sums him up: he’s a charismatic guy in scrubs who really appeals to a mass audience about how much he seems to care, so nobody really cares if he’s right or wrong.

I don’t know. The people watching his show want to be entertained and have their egos massaged by confirming their biases. They don’t want to think because thinking is painful for them. I don’t think they will appreciate Dr. Novella for this reason. They would have to think and not fantasize.

I am watching the show right now (thanks to Mr. Plumber who has to fix a shower faucet today). The spin of Dr. Oz is nothing short of astonishing. It’s a lesson on how to frame an argument. “Here’s what *your* doctor has to say.” (Not my doctor!) He repeatedly invokes the audience to create buy-in for his conclusions (without waiting for their answer).

But his first commercial cliff hanger left my mouth open. Is he really going to back down on supplements?

Nah…

PS – one bit of advice, if I may? Smile. Relax. You know your message. Smile and bring your audience into your argument.

First of all, I believe it’s a fatty omentum they are holding-I hate to admit that I actually saw that show way back.

I watched Dr. Novella’s segment. Not only was it interrupted by a tornado watch update, but it was only the first 15 minutes of the show. It needed to be the WHOLE show in order for any justice to be done to the topic and for Steve to have enough time to really make the points that needed to be made. Oz was the one who was very dismissive.
The bad part was in the end when Dr. Oz says something along the lines of “Don’t let anyone (i.e., your doctor) talk you out of any mumbo jumbo that makes sense to you.” In other words: It doesn’t matter if what you are doing is safe or if it actually works, as long as you feel it is a good idea that’s what counts. He’s utterly ridiculous.

As a dietitian, my wife frequently watches Dr. Oz, because her clients are always coming to her with crazy nutritional claims (e.g., adding coconut oil to food will make you lose weight) that they get from his show. I’m impressed that she manages to sit through the entire broadcast on a regular basis, although I do often hear her yelling, “That’s not how that works!” from the other room…

Having now seen it, I am very proud (if that isn’t too audacious or arrogant on my part) of Dr. Novella, and all of SBM. Although I’ve yet to hear or read anything from you or Dr. Novella about what was edited or removed, it seemed that all they did with his clips was make him nod in agreement to alternative claims (one of the cuts was *painfully* evident). If that’s the best they could do, then Dr. Novella did a damned good job.

I would like very much to never see another episode of Dr. Oz again, though.

Sadly, in my blogging gig I fear I will have to watch more episodes. (What I do for you people! It’s almost as bad as wading into the anti-vaccine websites!) After all, now that Oz has noticed us, the only thing to do is to keep up the heat.

I saw a sparring match where the home-town boy and his buddies got the better of the bout. One learns early-on that he who controls the mic controls the message. The misconception is that this was to be a debate or a presentation of views, a “fair fight”. Not so and in this format, it never will be. The expectation that this program (or any like it) would be even-handed is not realistic.
Dr. Novella has much knowledge that is valid and germane…I’ve been reading him for a while. But there was no chance that viewers would see him upstage the star. One can read Dr. Hall’s experience surrounding Oprah Winfrey to grasp what editors want to convey and how they do it. And that was for a health column!
I applaud Dr. Novella’s composure. He did himself no harm and probably did some good, but the fix was in.

I watched Dr. Novella’s part, but turned it off for the rest. I, too, picked up on the very obvious edit of Dr. Novella nodding in response to Dr. Oz correcting him (cringe!).

I thought Dr. Novella was very composed, and presented his points very well. Oz’s questions were a set-up though, so that Dr. Novella had to – in part – agree with much of what was presented as “alternative” (nutrition, meditation, exercise). He didn’t really seem to be given a chance at all to make an impact. I agree that Oz appeared to be the one more dismissive. Oz did not come off well in that segment either. The acupuncture discussion must have been heavily edited because it seemed bumpy, and Oz didn’t seem to have a credible comeback for the points Dr. Novella was making.

Overall, I’d say good job Dr. Novella! I’ve never liked Dr. Oz, but he seemed especially cringeworthy today. (And that cardiologist – why was she even there? She had no impact whatsoever).

Dr. Oz’s interview with Dr. Novella was like a kangaroo court presided over by a banana republic dictator. The outcome was pre-determined, only a show trial was needed to provide the “evidence.” Despite these severe limitations, Dr. Novella managed to present a laudable defense for science-based medicine.
The whole thing started with a leading question, “Why is your doctor afraid of alternative medicine,” which assumes your doctor IS afraid of alternative medicine. This is the equivalent of the classic leading question example: “When did you stop beating your wife?” Next was Dr. Oz’s converting Dr. Novella’s response indicating the evidence from quality trials did not support some supplements to a question addressed to the Natural Standards representative (forgot her name) which pretended Dr. Novella said there were no good clinical trials of supplements. Instead of correcting this obvious misrepresentation, the Natural Standard rep dutifully replied that this may have been true 10 years ago, but that now there are good clinical trials. When, in fact, no one had said that there weren’t. This is called “assuming facts not in evidence.” And, of course, there was the “government witness,” in the form of the Scripps physician (forgot her name too), who recommends acupuncture. As if the use of acupuncture acquitted all of “alternative medicine.”
And did Dr. Oz ever provide any actual evidence in support of “alternative” medicine? Not that I recall. His standard is: if it feels good, do it.
And if I may be permitted a question of Dr. Oz (which I most assuredly will not be), it is this: If someone who has no training in science (me) can figure out why “alternative medicine” is a bogus concept whose various treatments are devoid of scientific plausibility and evidence of effectiveness, why can’t you?

The question is, given Oz’s control of the discussion and unrebutted ending soliloquy, did Dr. Novella’s appearance change the minds of any of the woo-addled quack-backers who watch this crap or did it allow Oz to frame rational physicians as reactionaries fighting the emergence of powerful new modalities that just don’t fit the straight-jacketed western medical model?

As time went on, however, we did notice that, more and more, Dr. Oz seemed to want to “go with the flow” and “give the people what they want.” Why? we wondered. Dr. Val Jones, formerly a regular blogger for SBM, thought she knew the answer:

I told him that I was contributing to a blog called Science-Based Medicine in an effort to combat some of the medical quackery that is being promoted online. He looked at me and said I’d never be a success with that message. He said that people like Oprah and Mehmet Oz were successful because they “went with the flow” and gave people what they wanted.

“Most people don’t want to think critically about things – they want to hear about miracle cures, self-help, and vitamins. They already have the media they ‘deserve.’ You’ll never appeal to a mass audience with your skeptical message.”

========

Reading this, it appears at first that the “he”/”him” in Jones’ quote is Oz (that is what we do with pronouns, trace them back to the most recent plausible person in the preceding text) — it appears that Jones actually talked to Oz, and that the “most people don’t want to think…” quotation is FROM OZ. Which may me think “wow he is indeed a sellout and cynical guy but at least he is clear about what he is doing.” But then I paused and read again and saw that whoever “he” is mentions Oz and Winfrey in the third person… so apparently “he” is not Oz. Easy mistake to make in the fast-reading world we live in.

May I suggest that you edit the blog posting to better set up the quoted text from Jones? In her own posting Jones makes it clear that she was talking to a “business colleague”…

The FDA has issued a warning to Joseph Mercola, MD, that he has violated the Federal, Food, Drug, and Cosmetic Act by marketing the Meditherm Med2000 Telethermographic camera as a breast cancer screening tool.

According to the FDA, neither Mercola nor Meditherm have obtained marketing approval or clearance to market the camera as a stand-alone system to diagnose or screen breast disease. However, Mercola’s natural health website touts the camera as a stand-alone device to diagnose or screen for various diseases or conditions of the breast, the FDA wrote in a March 22 warning letter. These include: “Revolutionary and safe diagnostic tool detects hidden inflammation: thermography” and “The newest safe cancer screening tool.”

The FDA also charged that Mercola’s website implies that the Meditherm Med 2000 camera provides sensitivity greater than mammography.

In its warning letter, the FDA requested that Mercola cease making these and similar claims and noted that failure to correct “the violations promptly may result in the initiation of regulatory action [which may include] seizure, injunction, and/or civil monetary penalties.”

The initial 510(k) notification for Meditherm Med2000 Telethermographic camera, issued on Feb. 21, 2001, cleared the system “[f]or viewing and digitally storing thermal patterns generated by the human body in the clinical, hospital, acute care setting, surgery, healthcare practitioner facilities or in any environment where healthcare is provided by a qualified healthcare professional.”